Burns / management of burn wounds

Background
The principles of managing burns in children are similar to those for adults, but burn depth assessment is
often more difficult due to their thinner skin. Children also require burns resuscitation fluid at a lesser total
body surface area (TBSA) percentage than adults (10% in children as opposed to 20% in adults). Beware
hypothermia during initial cooling, especially in young children.

Initial management
First aid

Commence cooling as soon as possible (within 3 hours from time of burn), with cool, running water
for 20 minutes total duration. Cooling should be targeted to the affected area only.

 Do NOT apply ice or ice slush as this may cause additional tissue damage.
 Do NOT apply hydrogel burn products (e.g. Burnaid®) as a first aid measure UNLESS there is no
access to a water source.
 Cold water compresses are less effective than running water to cool a burn wound, and must be
changed frequently.
 Applying plastic (cling) wrap to burn wound after cooling aids analgesia and limits heat loss and
evaporation.
 Irrigate any chemical burns with copious volumes of water.
 Burns to the eyes require early irrigation with copious volumes of normal saline or water.

Pain relief

 Immediate, effective analgesia should be provided, with the route and choice of analgesia
determined by the condition of child and potency of analgesia required.
 Rapid options include intranasal fentanyl (1.5 mcg/kg) or IV morphine (0.1mg/kg given in titrated
boluses).
 Dressing changes should be accompanied by appropriate analgesia and sedation.
 For further information on analgesia options, see Analgesia and sedation guidelines

Assessment
Airway and breathing

 Assess for presence of stridor, hoarseness, black sputum or respiratory distress, singed nasal
hairs or facial swelling.
  Any child with oropharyngeal burns and/or significant neck burns must be considered for
intubation, even if the airway is not yet compromised; early involvement of senior airway expertise
in discussion with PIPER is essential for safe airway management.
 Protect the cervical spine with midline immobilisation if associated trauma.
 Apply high flow oxygen via non-rebreather mask (up to 15 L/min).
 Full thickness chest burns may require escharotomy to permit chest expansion.

Circulation

 Early hypovolaemia is rarely related to the burn injury and other sources of bleeding should be
sought.
 For circumferential burns, check for signs of impaired peripheral perfusion and the need for
an escharotomy. Irrespective of whether an escharotomy is need, ALWAYS ELEVATE the
affected limb(s).
 High voltage electrical limb burns may require early fasciotomy, seek surgical opinion early as
may have extensive tissue damage without obvious external signs.

Estimation of surface area

 Use a Burn diagram (LUND-BROWDER) to accurately calculate the Total Body Surface Area
(TBSA) of the burn wound. Do NOT include areas of burnt skin with erythema only
(epidermal burn) as this is not relevant to a TBSA calculation.
 As a rough measure, the child's palm (not the examiner’s) represents 1% TBSA.
 TBSA of the burn wound determines need for fluid resuscitation and admission.

Burns depth assessment

 Burns depth assessment may be difficult, the table below aids accurate estimation of burn depth.
 Suspicion of deep partial thickness or full thickness burns warrants referral.
Depth Cause Surface/colour Pain sensation

Superficial Sun, flash, minor Dry, minor blisters, Painful

scald erythema, brisk
capillary return

Superficial Partial Scald Moist, reddened with Painful

thickness - broken blisters, brisk
(superficial dermal) capillary return

Deep Partial Scald, minor Moist white slough, Painless

thickness - (deep flame contact red mottled, sluggish
dermal) capillary return

Full thickness Flame, severe Dry, charred whitish. Painless

scald or flame Absent capillary
contact return

Acute management of major burns, >10% TBSA

Children with burns >10% TBSA need early discussion with PIPER (1300 137 650), and through
PIPER with the relevant Burn Unit, regarding acute management and transfer.

Airway and breathing

 All burns patients require a thorough primary survey as detailed above.
 If suspicion of airway burns, consider application of high flow oxygen.
 Whenever possible, the decision to intubate should be discussed first with PIPER and/or a
local airway expert.

Fluids
Children with burns >10% TBSA require both resuscitation and maintenance fluids: see intravenous
fluids guideline.
Resuscitation fluids, ideally through 2 large bore IV/IO, through uninvolved skin at a volume/rate
estimated using the Modified Parkland’s Formula:
3-4mls x kg x % TBSA (24 hour total volume) with Hartmann’s solution

 Commence rate to give 50% of this volume in first 8 hours from time of injury (not time
of presentation); if >8 hours since injury discuss fluids with PIPER
 Ongoing resuscitation fluid rates are guided by urine output, and vital signs.
 Aim for urine output 1mL/kg/hr, with resuscitation fluid rate increased or decreased
accordingly.

Maintenance fluids: see intravenous fluids guideline.

Total fluid volume is the sum of resuscitation and maintenance fluid calculations.
Adjuncts in major burns – urinary catheter, gastric tube

 Who needs these adjuncts?

All children with >10% TBSA burns require insertion of both a urethral catheter and gastric
tube. Children with perineal/genital burns also need consideration for a urinary catheter,
irrespective of the TBSA.
 When should they be inserted?
Timing of insertion relative to referral and transfer varies with each case, and consultation
with PIPER or the receiving Burn Unit prior to insertion is advised. Perineal/genital burns
warrant early insertion.

Investigations
 Standard: Hb, electrolytes, blood glucose, blood group and hold.
 Select cases:
 a) Carbon monoxide (blood gas) if suspected inhalation injury;
 b) ECG if electrical burn
 c) bHCG if female patient of reproductive age

Document the following:

 Time of burn
 Extent - Burn diagram
 Depth
 First aid
 Tetanus status

Management of minor burns (isolated, <10% TBSA)

 Analgesia: may be required for assessment and initial dressings (see initial management).
 Consider sling and splinting for more extensive upper limb burns.
 Check Tetanus status.
 Dressings that can remain in situ for 3-7 days are recommended for partial thickness burns.
 The depth of a partial thickness burn may only be declared after 7-10 days.
  Evidence regarding the management of blisters is limited, but de-roof/debride if blister is
large or overlying a joint

Examples of burns dressings

Superficial burns with erythema only

 Can be treated without dressing. In infants who show a tendency to blister or scratch, a
protective, low-adherent dressing (e.g. Mepitel™ + Melolin™) with crepe bandage may be
helpful.

Partial thickness burns

 Cleanse the burn wound and surrounding surface with water or saline and pat dry.
 For small, superficial partial thickness burn wounds, a low adherent dressing (e.g. BactigrasTM +
Melolin™ or Mepilex-AgTM) then crepe bandage or tape (e.g. HypafixTM)
 For more extensive or deeper partial thickness burn wound, a low-adherent silver dressing (e.g.
Acticoat™ or Acticoat 7™) should be applied.
Facial burns

 Cleanse burn with sterile water or saline.

 Superficial burns only require Vaseline™ to be applied twice daily, whereas partial thickness
burns may need silver dressings. Good education regarding care of the burn is essential - see
handout Burns on the face
 For more details and advice regarding specific area burns, please see the RCH Burns Unit
clinical information

*Although references are made to specific products in this guideline, it is possible that other products
may be suitable to use in their place. Seek advice from the Product Information, treating physician or
dressings specialist.

Consider consultation with local paediatric team

 Concern regarding non-accidental injury

 Multiple co-morbidities
 Concern regarding social situation or dressing compliance

When to refer to burn unit

 All full thickness burns.
 All burns to face, ears, eyes, hands, feet, genitalia, perineum or a major joint, even if less than
10% (excluding areas of erythema only).
 Circumferential burns.
 Chemical burns.
 Electrical burns. Extensive tissue damage can occur to underlying structures.
 Burns associated with significant fractures or other major injury.
 All inhalation or airway burns.
 Burns in children under the age of 12 months.
 Child requiring care beyond the comfort level of the hospital, or advice regarding appropriate
dressings or disposition.

Transfer of patients from other hospitals for assessment

 If time from burn to arrival at burn unit is less than 6 hours and the burn is clean:
 Wash with saline, cover with plastic cling wrap for transfer (do not wrap), allowing for easy
assessment at the burns centre without undue discomfort from removal of dressings.

Follow up

 Burns can evolve over time. Consider a follow up within 3 days of initial presentation to reassess
depth, monitor healing and determine ongoing management.
 If burn depth is unclear after 3 - 5 days, referral to a burn unit is warranted.
 Burn injuries that are slow to heal (e.g. poor progression at 5-7 days) should be referred for
outpatient review by a Burn Unit.